The Adverse Childhood Experiences (ACE) Study The largest study of its kind ever to examine over the lifespan the medical, social, and economic consequences in adults of adverse childhood experiences. (17,337 participants)
The ACE Study Summary of Findings: Adverse Childhood Experiences (ACEs) are very common, but largely unrecognized. ACEs are strong predictors of later death, disease, health risks, social functioning, well-being, and medical care costs. ACEs are the basis for much of adult medicine and of many major public health and social problems. Adverse childhood experiences are interrelated, not solitary. This combination makes Adverse Childhood Experiences the prime determinant of the health, social, and economic well-being of our nation.
ACE Study Design Survey Wave 1 71% response (9,58/13,454) n=13, All medical evaluations abstracted Survey Wave II n=13, All medical evaluations abstracted vs. Present Health Status 17,337 adults Mortality National Death Index Morbidity Hospitalization Doctor Office Visits Emergency Room Visits Pharmacy Utilization
Prevalence of Adverse Childhood Experiences Prevalence (%) Abuse, by Category Psychological (by parents) 11% Physical (by parents) 28% Sexual (anyone) 22% Neglect, by Category Emotional 15% Physical 1% Household Dysfunction, by Category Alcoholism or drug use in home 27% Loss of biological parent < age 18 23% Depression or mental illness in home 17% Mother treated violently 13% Imprisoned household member 5%
Adverse Childhood Experiences Score Number of categories (not events) is summed Prevalence 33% 1 25% 2 15% 3 1% 4 6% 5 or more 11%* Two out of three experienced at least one category of ACE. If any one ACE is present, there is an 87% chance at least one other category of ACE is present, and 5% chance of 3 or >. * Women are 5% more likely than men to have a Score >5.
Well-being Childhood Experiences Underlie Chronic Depression % With a Lifetime History of Depression 8 7 6 5 4 3 2 1 1 2 3 >=4 Women Men
Well-being 25 Childhood Experiences Underlie Suicide Attempts 2 4+ % Attempting Suicide 15 1 5 1 2 3
Costs and Rates of Antidepressant Prescriptions approximately 5 years later 1 Prescription rate per 1 person-years) 9 8 7 6 5 4 3 2 1 1 2 3 4 5 or more
Well-being and Hallucinations Ever Hallucinated* (%) Abused Alcohol or Drugs *Adjusted for age, sex, race, and education.
Well-being and Impaired Memory of Childhood 4 Percent With Memory Impairment (%) 35 3 25 2 15 1 2 3 >=4 2 3 4 1 5 1
Health Risks 2 18 16 Adverse Childhood Experiences vs. Smoking as an Adult % 14 12 1 8 6 4 2 1 2 3 4-5 6 or more p<.1
Health Risks 18 Childhood Experiences vs. Adult Alcoholism 16 14 4+ % Alcoholic 12 1 8 6 2 3 4 1 2
Health risks vs Injection Drug Use % Have Injected Drugs 3.5 3 2.5 2 1.5 1.5 1 2 3 4 or more p<.1
Health risks, Social function: Looking for Love vs > 5 Sexual Partners 4 Adjusted Odds Ratio 3 2 1 1 2 3 4 or more
Social function and Teen Sexual Behaviors Looking for love 45 Percent With Health Problem (%) 4 35 3 25 2 15 1 5 1 2 3 4 or more Intercourse by 15 Intercourse by Age 15 Teen Pregnancy Teen Pregnancy Teen Paternity Teen Paternity
Well-being Childhood Experiences Underlie Later Being Raped 35 % Reporting Rape 3 25 2 15 1 1 2 3 4 + 5
Social function: and the Risk of Perpetrating Domestic Violence 15 1 Women Men 5 1 2 3 4 >5 1 2 3 4 >5
Social function: and Indicators of Impaired Worker Performance 25 2 1 2 3 4 or more 15 1 5 Absenteeism ( > 2 days/month) Serious Financial Problems Serious Problems Performing job
Biomedical Disease The and the Prevalence of Liver Disease (Hepatitis/Jaundice) 12 1 Percent (%) 8 6 4 2 1 2 3 >=4 AACE CE Score
Biomedical Disease vs. COPD Percent with Problem 18 16 14 12 1 8 6 4 2 1 2 3 4 COPD
Biomedical disease ACEs Increase Likelihood of Heart Disease* Emotional abuse 1.7x Physical abuse 1.5x Sexual abuse 1.4x Domestic violence 1.4x Mental illness 1.4x Substance abuse 1.3x Household criminal 1.7x Emotional neglect 1.3x Physical neglect 1.4x * After correction for age, race, education, and conventional risk factors like smoking and diabetes. Circulation, Sept 24.
Effect of ACEs on Death Rate (Null hypothesis) Percent in Age Group 6 5 4 3 2 1 2 4 Age Group 19-34 35-49 5-64 >=65
How and why do Adverse Childhood Experiences exert their influence throughout life? Why is treatment so difficult?
In Summary, the ACE Study indicates: Adverse childhood experiences are the most basic and long-lasting cause of health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs.
Adverse Childhood Experiences Underlie these National Problems adult biomedical health reproductive health smoking alcohol abuse illicit drug use sexual behavior mental health risk of re-victimization stability of relationships performance in the workforce
A Public Health Paradox What are conventionally viewed as Public Health problems are often personal solutions to long-concealed adverse childhood experiences.
What Can We Do Today? Routinely seek a history of adverse childhood experiences from all patients/inmates, by questionnaire. Acknowledge their reality by asking, How has this affected you later in your life? Use existing systems to help with current problems. Develop systems for primary prevention.
Final Insights from the ACE Study Adverse childhood experiences are common but typically unrecognized. Their link to major problems later in life is strong, proportionate, and logical. They are the nation s most basic public health problem. It is comforting to mistake intermediary mechanism for basic cause. What presents as the Problem may in fact be an attempted solution. Treating the solution may threaten people and cause flight from treatment. Change will be resisted by us in spite of enormous benefits.